Supplemental calcium for the prevention of hip fracture: potential health-economic benefits

[Direct medical costs of hospital treatment of fractures of the upper extremity of the femur]

Fractures of the upper extremity of the femur are serious because of their morbidity and social and/or economic consequences. They have been the subject of several studies of world literature concerning their hospital treatment, evolution and prevention. The increase in the incidence of this pathology seems unavoidable due to population ageing and to the lengthening life expectancy; it is posing a real long-term public health problem whose importance will be further increased by the need to control health care costs. The results of this study show that the average age of onset of fracture of the proximal extremity of the femur is 68,13 ± 16.9 years, with a male predominance and a sex ratio of 1.14. In our study pertrochanterian fractures represented 69.4% of cases. Direct medical costs of the hospital treatment of fractures of the upper extremity of the femur at the Hassan II University Hospital were £387 714,38 in 222 cases, with an average cost of £1757,4 , including costs for patient's stay in hospital, which represented the majority of expenses ( 77% of total costs). It is desirable to raise staff awareness of the costs of consumables in order to reduce treatment costs and to adopt cost-oriented behaviour. Length of stay should be limited to the maximum extent because it only allows to reduce staff and accommodation costs.

Inulin-type fructans and bone health: state of the art and perspectives in the management of osteoporosis

If the primary role of diet is to provide sufficient nutrients to meet the metabolic requirements of an individual, there is an emerging rationale to support the hypothesis that, by modulating specific target functions in the body, it can help achieve optimal health. Regarding osteoporosis prevention, since Ca is most likely to be inadequate in terms of dietary intake, every strategy targeting an improvement in Ca absorption is very interesting. Actually, this process may be susceptible to manipulation by fermentable substrates. In this light, inulin-type fructans are very interesting, even if we need to gather more data targeting bone metabolism before health professionals can actively advocate their consumption to prevent senile osteoporosis. Besides targeting the prevention of postmenopausal osteoporosis, inulin-type fructans still remain a source for putative innovative dietary health intervention. Indeed, given in combination with isoflavones, they may have a potential for maintaining or improving the bone mass of human subjects, by modulating the bioavailability of phyto-oestrogens.

The Canadian Health Claim for Calcium, Vitamin D and Osteoporosis

To provide evidence for or against allowing a health claim for calcium in Canada, we undertook a review of the current U.S. health claim for calcium and osteoporosis, and also reviewed the scientific literature published since that health claim was first proposed and reviewed by the U.S. Food and Drug Administration in 1991 and adopted in 1993. Our objectives were 1) to determine if the science behind the claim was still valid, and if so, 2) to recommend any new wording to the claim, if warranted, prior to implementation in Canada. Based on a review of the evidence (to May 2000) related to the various claim elements, the following health claim for calcium has been established in Canada: A healthy diet with adequate calcium and vitamin D, and regular physical activity, help to achieve strong bones and may reduce the risk of osteoporosis. The compositional criteria for foods bearing this claim are that the food must provide at least 200 mg calcium per serving and that the phosphorus content (excluding that provided by phytate) must be less than the calcium content.

Cost-effectiveness of fracture prevention treatments in the elderly

Objectives:The cost-effectiveness of fracture prevention treatments (vitamin D and calcium and hip protectors) in male and female populations older than seventy years of age in the United-Kingdom was investigated.

Methods:A Markov model was developed to follow up, over lifetime, a hypothetical cohort of males and females at high-risk and general risk of fracture. Patients could sustain hip, wrist, vertebral, and/or other fractures. Fracture rates were obtained from population surveys in the United Kingdom. Effectiveness and quality of life data were identified from the clinical literature. Costs were those incurred by the UK National Health Service, and were obtained from several published sources. Uncertainty was explored through probabilistic sensitivity analysis.

Results:In the general-risk female (male) population, the incremental cost per Quality Adjusted Life Year (QALY) was $11,722 ($47,426) for hip protectors. In the male high-risk population, the incremental cost per QALY was $17,017 for hip protectors. In the female high-risk population, hip protectors were cost-saving. Vitamin D and calcium alone was dominated by hip protectors in all four subgroups.

Conclusions:Current information available on interventions to prevent fractures in the elderly in the United Kingdom, suggests that, at the decision-maker's ceiling ratio of $20,000 per QALY, hip protectors are cost-effective in the general female population and high-risk male population, and cost-saving in the high-risk female population, despite the low compliance rate with the treatment.

Determinants of osteoporosis prevention in low-income Mexican-American women

BACKGROUND

Prevention is the most cost-effective means of managing osteoporosis. However, little is known about osteoporosis-related preventive practices in Mexican-American women. We examined factors that might influence women's decision to start preventive measures for osteoporosis.

METHODS

Information was gathered through a cross-sectional survey of low-income Mexican-American women who were seen at two clinics in southern Texas.

RESULTS

Of the 270 participants, 37% reported calcium supplementation, and 41% reported regular weight-bearing exercise to prevent osteoporosis. Fifty (41%) of the postmenopausal women were currently using hormone replacement therapy. Only 15% of the premenopausal and 13% of the postmenopausal women recalled that their health care provider had counseled them about prevention. Multivariate analysis showed that public education, bone densitometry evaluation, knowledge of osteoporosis, and counseling were determinants of prevention.

CONCLUSION

Although osteoporosis is a preventable condition, our findings suggest that the majority of Mexican-American women do not receive adequate preventive measures or counseling about osteoporosis. Furthermore, we found that their health care provider's counseling about osteoporosis was a major determinant of osteoporosis prevention in these women.

Calcium-vitamin D3 supplementation is cost-effective in hip fractures prevention

OBJECTIVE

To assess the cost implications for a preventive treatment strategy for institutionalised elderly women with a combined 1200 mg/day calcium and 800 IU/day vitamin D(3) supplementation in seven European countries.

DESIGN

Retrospective cost effectiveness analysis based on a prospective placebo-controlled randomised clinical trial.

DATA SOURCES

Recently published cost studies in seven European countries. Clinical results from Decalyos, a 3-year placebo-controlled study in elderly institutionalised women.

TRIALS

Decalyos study, with 36 months follow-up of 3270 mobile elderly women living in 180 nursing homes, allocated to two groups. One group received 1200 mg/day elemental calcium in the form of tricalcium phosphate together with 800 IU/day (20 microg) of cholecalciferol (vitamin D(3)), the other placebo.

RESULTS

In the 36 months analysis of the Decalyos study, 138 hip fractures occurred in the group of 1176 women, receiving supplementation and 184 hip fractures in the placebo group of 1127 women. The mean duration of treatment was 625.4 days. Adjusted to 1000 women, 46 hip fractures were avoided by the calcium and vitamin D(3) supplementation. For all countries, the total costs in the placebo group were higher than in the group receiving supplementation, resulting in a net benefit of 79000-711000 per 1000 women.

CONCLUSION

This analysis suggests that the supplementation strategy is cost saving. The results may underestimate the net benefits, as this treatment has also shown to be effective in decreasing the incidence of other non-vertebral fractures in elderly institutionalised women.

Estimating hip fracture morbidity, mortality and costs

OBJECTIVES

To estimate lifetime morbidity, mortality, and costs from hip fracture incorporating the effect of deficits in activities of daily living.

DESIGN

Markov computer cohort simulation considering short- and long-term outcomes attributable to hip fractures. Data estimates were based on published literature, and costs were based primarily on Medicare reimbursement rates.

SETTING

Postacute hospital facility.

PARTICIPANTS

Eighty-year-old community dwellers with hip fractures.

MEASUREMENTS

Life expectancy, nursing facility days, and costs.

RESULTS

Hip fracture reduced life expectancy by 1.8 years or 25% compared with an age- and sex-matched general population. About 17% of remaining life was spent in a nursing facility. The lifetime attributable cost of hip fracture was $81,300, of which nearly half (44%) related to nursing facility expenses. The development of deficits in ADLs after hip fracture resulted in substantial morbidity, mortality, and costs.

CONCLUSION

Hip fractures result in significant mortality, morbidity, and costs. The estimated lifetime cost for all hip fractures in the United States in 1997 likely exceeded $20 billion. These results emphasize the importance of current and future interventions to decrease the incidence of hip fracture.

Micronutrients in women's health and immune function

Lawrence J. Machlin's contributions to elucidating the roles of nutrients in optimizing human health included the support of research in the areas of women's health and immune function. Several essential nutrients have been shown to affect women's health throughout the different life stages. Symptoms of premenstrual syndrome affect the vast majority of menstruating women, and calcium supplementation significantly reduces physical and emotional symptoms. Premenstrual syndrome in fact might be a predictor of osteoporosis induced by low calcium intake. Periconceptional multivitamin supplementation has reduced the risk of serious birth defects, premature delivery, and low birth weight by 50% and improved maternal health during pregnancy. Micronutrients of particular importance for prevention of adverse pregnancy outcomes are folic acid, zinc, and iron. However, if the preterm delivery is caused by preeclampsia, then data suggest that calcium supplementation and high doses of vitamins C and E significantly reduce that risk. Well-controlled studies consistently have shown that calcium supplementation, with or without vitamin D, significantly reduces the risk of hip fracture. Antioxidants such as vitamins C and E have been shown to reduce the risk of fracture in women smokers. As in the rapidly growing embryo, the immune system includes rapidly multiplying cells whose functions are dramatically affected by an individual's micronutrient status. Multivitamins have been shown to enhance many aspects of immune response, and antioxidant micronutrients consistently have been found to enhance lymphocyte-proliferative responses and skin-test responses, especially in the elderly.

Absorbability and cost effectiveness in calcium supplementation

BACKGROUND

Cost-effectiveness of calcium supplementation depends not only on the cost of the product but on the efficiency of its absorption. Published cost-benefit analyses assume equal bioavailability for all calcium sources. Some published studies have suggested that there are differences in both the bioavailability and cost of the major calcium supplements.

DESIGN

Randomized four period, three-way cross-over comparing single doses of off-the-shelf commercial calcium supplements containing either calcium carbonate or calcium citrate compared with a no-load blank and with encapsulated calcium carbonate devoid of other ingredients; subjects rendered fully vitamin D-replete with 10 microg/day 25(OH)D by mouth, starting one week prior to the first test.

SUBJECTS

24 postmenopausal women

METHODS

Pharmacokinetic analysis of the increment in serum total and ionized calcium and the decrement in serum iPTH induced by an oral calcium load, based upon multiple blood samples over a 24-hour period; measurement of the rise in urine calcium excretion. Data analyzed by repeated measures ANOVA. Cost calculations based on average retail prices of marketed products used in this study from April through October, 2000.

RESULTS

All three calcium sources (marketed calcium carbonate, encapsulated calcium carbonate and marketed calcium citrate) produced identical 24-hour time courses for the increment in total serum calcium. Thus, these were equally absorbed and had equivalent bioavailability. Urine calcium rose slightly more with the citrate than with the carbonate preparations. but the difference was not significant. Serum iPTH showed the expected depression accompanying the rise in serum calcium, and there were no significant differences between products.

CONCLUSION

Given the equivalent bioavailability of the two marketed products, the cost benefit analysis favors the less expensive carbonate product.

Nutrition in bone health revisited: a story beyond calcium

Osteoporosis is a complex, multi-factorial condition characterized by reduced bone mass and impaired micro-architectural structure, leading to an increased susceptibility to fractures. Although most of the bone strength (including bone mass and quality) is genetically determined, many other factors (nutritional, environmental and life-style) also influence bone. Nutrition is important modifiable factor in the development and maintenance of bone mass and the prevention and treatment of osteoporosis. Approximately 80-90% of bone mineral content is comprised of calcium and phosphorus. Other dietary components, such as protein, magnesium, zinc, copper, iron, fluoride, vitamins D, A, C, and K are required for normal bone metabolism, while other ingested compounds not usually categorized as nutrients (e.g. caffeine, alcohol, phytoestrogens) may also impact bone health. Unraveling the interaction between different factors; nutritional, environmental, life style, and heredity help us to understand the complexity of the development of osteoporosis and subsequent fractures. This paper reviews the role of dietary components on bone health throughout different stages of life. Each nutrient is discussed separately, however the fact that many nutrients are co-dependent and simultaneously interact with genetic and environmental factors should not be neglected. The complexity of the interactions is probably the reason why there are controversial or inconsistent findings regarding the contribution of a single or a group of nutrients in bone health.

Use of vitamin-mineral supplements by female physicians in the United States

BACKGROUND

Rates of vitamin-mineral supplement use by US female physicians are unknown but are of particular interest for several epidemiologic and clinical reasons.

OBJECTIVE

The objective was to determine rates of and variations in vitamin-mineral supplement use among US female physicians.

DESIGN

We used data from the Women Physicians' Health Study, a large (n = 4501) national, randomly sampled mail survey of female physicians aged 30-70 y.

RESULTS

Half of the physicians took a multivitamin-mineral supplement; 35.5% of these did so regularly. However, </=33% took any supplement other than calcium and <20% did so regularly. Regular vitamin-mineral supplement use increased with age, and antioxidant intake was higher in those at high risk of heart disease. Those with a history of osteoporosis were nearly 3 times as likely as those with no history to take supplemental calcium regularly. Those who took any supplement regularly also consumed more fruit and vegetables daily than did occasional users or nonusers (P: < 0.0001). Regular users of any supplement also consumed less fat than did occasional users or nonusers (P: < 0.01). Additionally, vegetarians were more likely than were nonvegetarians to regularly consume any supplement (59.9% compared with 46.3%; P: < 0.001) and those who regularly consumed any supplement were more likely to comply with US Preventive Services Task Force guidelines than were those who were occasional users or nonusers (72.4% compared with 66.5% and 60.2%; P: < 0.0001).

CONCLUSION

Female physicians, particularly those who were especially health conscious or at higher risk of heart disease or osteoporosis, used supplements at rates at least equal to those of women in the general population.

An injectable cementing screw for fixation in osteoporotic bone

With the aging population, osteoporosis and osteoporotic fractures are becoming more prevalent. Adequate screw fixation in this type of bone is difficult. Screws are often cemented in bone to help obtain purchase. However, current cementing techniques do not ensure implant stability. Here we present a new cannulated screw with side ports that can be injected with polymethylmethacylate (PMMA) for fixation in osteoporotic bone. We compared the ultimate holding power of this cannulated screw injected with PMMA to a solid screw with the same dimensions secured with PMMA by the standard technique. Both screws were placed into embalmed and fresh frozen lumbar vertebral bodies and pulled out using a mechanical testing system. The cannulated screw had a 278% greater holding power compared to the standard screw (p < 0.006). The cannulated screw provided a significant increase in holding power in osteoporotic bone. This novel screw is promising for fixation in osteoporotic bone and warrants clinical evaluation.